Abstract | March 11, 2024

Acute Type A Aortic Dissection Complicated by Hepatic Hypoperfusion Treated with Intravascular Ultrasound-Guided Celiac Artery Stent

Hailey Shoemaker, MPH, Medical Student, Year 3, Kaiser Permanente School of Medicine, Pasadena, CA

Aldin Malkoc, MD, General Surgery, PGY3, Arrowhead Regional Medical Center, Colton, California; Amira Barmanwalla, MD, General Surgery, PGY 5, Arrowhead Regional Medical Center, Colton, California; Raja Gnanadev, MD, General Surgery, PGY 4, Arrowhead Regional Medical Center, Colton, California; Amanda Daoud, MD, General Surgery, PGY 4, Arrowhead Regional Medical Center, Colton, California; Majid Tayyarah, MD, Vascular Surgery, Kaiser Permanente Fontana Medical Center, Fontana, CA

Learning Objectives

  1. Describe end-organ complications secondary to Type A aortic dissection and a possible time course for their development, as not all damage is evident at presentation and multiple interventions may be required
  2. Describe the warning signs, including imaging and laboratory values, indicating end-organ complications warranting further evaluation as mentioned above
  3. Discuss the potential treatment options for organ malperfusion or impending organ failure secondary to extension of an aortic dissection into a branch vessel (celiac trunk, superior mesenteric artery, etc)

Introduction: Type A aortic dissection is a common deadly cardiovascular emergency requiring prompt corrective surgery (1). Potential complications of the dissection itself, surgery, and cardiopulmonary bypass include aortic arch or branch occlusion, thrombosis, and eventual ischemia of vital organs (1, 2). Occlusion of the celiac artery leading to liver malperfusion in this setting requires prompt surgical care to avoid fulminant liver failure and death (3, 4, 5). However, the most effective approach has not yet been established in the literature.

Case Presentation: In this report, we describe a 39-year-old female patient with hypertension who presented with severe acute chest pain radiating to the upper back. Physical exam findings on admission included hypertensive urgency, equal radial pulses, and no neurologic deficits. Computed tomography (CT) angiogram of the chest showed a Stanford Type A, Debakey Type I aortic dissection involving the aortic takeoff from the heart, aortic arch, and common iliac arteries, with partial involvement of the celiac axis and superior mesenteric artery (SMA). One day after emergent total arch replacement, she developed acute kidney injury, leukocytosis, lactic acidosis, and elevated INR. CT scan of the abdomen and pelvis showed bowel edema, pelvic free fluid, and redemonstration of the previous dissection involving the celiac trunk and SMA. The celiac artery appeared to have a central stenosis, presumably due to the dissection flap.

Working Diagnosis: Our patient suffered from imminent hepatic failure secondary to a celiac artery dissection in the setting of Type A aortic dissection.

Management and Outcome: Hepatic reperfusion was achieved through ultrasound-guided balloon angioplasty of the celiac artery with placement of a bare-metal stent extending into the common hepatic artery to prevent recurrence. The patient’s INR and hepatic function tests normalized by 20 days post-arch replacement, indicating that stent placement prevented acute fulminant hepatic failure and patient mortality. Her clinical course was unfortunately complicated by left hemispheric cerebral infarction and hemodialysis-dependent acute renal failure. On postoperative day 20, she was discharged to a neurological skilled nursing facility for further care.

References and Resources

  1. Kim JH, Roh BS, Lee YH, Choi SS, So BJ. Isolated spontaneous dissection of the superior mesenteric artery: percutaneous stent placement in two patients. Korean J Radiol. 2004;5(2):134–8.
  2. Vaidya S, Dighe M. Spontaneous celiac artery dissection and its management. J Radiol Case Rep. 2010;4(4):30-33.
  3. Sommerville RS, Atherton J, Leditschke IA, Fraser JF. Acute hepatic failure caused by an acute aortic dissection with cardiac tamponade: a case report. Crit Care Resusc. 2004;6(2):105-108.
  4. Zhou W, Wang G, Liu Y, et al. Outcomes and risk factors of postoperative hepatic dysfunction in patients undergoing acute type A aortic dissection surgery. J Thorac Dis. 2019;11(8):3225-3233.
  5. Pérez Vela JL, Jimenez Rivera JJ, Alcala Llorente MA, et al. Low cardiac output syndrome in the postoperative period of cardiac surgery. Profile, differences in clinical course and prognosis. The ESBAGA study. Med Intensiva 2018;42:159-67.
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